3. Sheffield Microsystem Coaching Academy Network Event 3 rd October 2013

4. Agenda TopicTime Welcome – Steve Harrison12.00 NHS England, Overview and Patient Safety Priorities - Bruce Warner 12.05 Questions & Discussion12.45 Informal Networking13.00 Close13.30

5. Microsystems Coaching Academy Aim To improve the quality and value of care we provide in the Sheffield Healthcare system Through the development of team coaching To build improvement capability at the front line with knowledge, processes and tools including the Dartmouth Microsystem Improvement Curriculum. 4

6. It’s about redesigning the system “Every system is perfectly designed to get the results it gets.” Paul B. Batalden, MD Co-Founder The Institute for Healthcare Improvement Founding Director, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice Founding Director, Healthcare Improvement Leadership Development The Dartmouth Institute for Health Policy and Clinical Practice Co-Founder Institute for Healthcare Improvement 5

7. Team Coaching Improvement Science Microsystem Improving Microsystems - Elements QI

8. Want more information? www.sheffieldmca.org.uk Stories & case Studies Events (Open Invite) Apply to be a Coach Apply to have your team coached

9. Dr. Bruce Warner Deputy Director of Patient Safety NHS England NHS England Overview and Patient Safety Priorities

10. Dr. Bruce Warner Deputy Director of Patient Safety NHS England

11. OLD! Flowchart For Problem Resolution Don’t Mess About With It! YES NO YES You Daft Prat NO Will it Blow Up In Your Hands? NO Deny All Knowledge Anyone Else Know? You’re stuffed! YES NO Hide It under a desk Can You Blame Someone else? NO SORTED! Yes Is It Working? Did You Mess About With It?

12. International and National Recognition of Patient Safety 11 1999 2000 2001

13. 2001 National Patient Safety Agency Established Collect and analyse information on adverse events Assimilate other safety-related information Learn lessons and ensure that they are fed back into practice Where risks are identified, produce solutions to prevent harm

14. June 2012 - National Patient Safety Agency Abolished 2 “We propose to abolish the National Patient Safety Agency” “ The work of the Patient Safety Division relating to reporting and learning from serious patient safety incidents should move to the NHS Commissioning Board… … covering the whole function from getting evidence to working up evidence-based safe services.”

15. Time to Move On NPSA Patient Safety Division Patient Safety Function to NHSCB(A) NRLS to ICHT 14

16. What is NHS England? Create the culture and conditions for health and care services and staff to deliver the highest standard of care and ensure that valuable public resources are used effectively to get the best outcomes for individuals, communities and society for now and for future generations 6,500 people in new roles in national, regional, and local offices across England

17. Role of NHS England NHS England has three distinct but interconnected roles: Directly commissioning primary care, specialised, armed forces and justice health services System wide leader for quality improvement Supporting and enabling the local commissioning system (CCGs and Area Teams) £26bn in 2012/13 CCGs were allocated £65bn in 2012/13 Working with partners: CQC, Monitor, NHS TDA, NICE, HSC IC, HEE CCGs, CSUs, NHSIQ, NHS Leadership Academy, Local Gov

18. The Mandate Government sets annual objectives that NHS England are legally obliged to pursue, but NHS England is independent in pursuing those objectives NHS England is held accountable to the government against the achievement of those objectives, and the level of continuous improvement

19. First Mandate for NHS England Sets out what the Government expects in return for handing over £95bn of tax payers money to NHS England The NHS Outcomes Framework sits at the heart of this Mandate. NHS England is expected to demonstrate progress across the entire framework

20. NHS Outcomes Framework

21. We need to make this vision a reality, translating it into how patients care looks and feels

22. NHS Outcomes Framework Structure

23. Domain teams priority action areas Maximising the contribution that the NHS can make to preventing disease Finding the ‘missing millions’ and diagnosing earlier and more accurately Treating people in an appropriate and timely way Addressing unwarranted variation in mortality and survival rates Reducing deaths in babies and young children Preventing people from dying prematurely Enhancing the quality of life for people with long term conditions Helping people to recover from episodes of ill health or following recovery Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting from avoidable harm 1 1 2 2 3 3 4 4 5 5 DOMAINS Helping patients take charge of their care Enabling good primary care Ensuring continuity of care Ensuring a parity of esteem for mental health Keeping people out of hospital when appropriate Effective interfaces between primary, secondary and community care High quality, efficient care for people in hospital Co-ordinated care and support for people following discharge from hospital Improving our understanding of the patient experience Reduce inequality in patient experience Enabling commissioners and providers to create a culture that puts good patient experience and positive staff experience at the heart of services Establishing clear lines of accountability for patient experience in the NHS Increase our understanding of the problem Create the conditions for patient safety Build capacity for safe care Create a whole system response Address our key patient safety concerns

24. NHS | Presentation to [XXXX Company] | [Type Date] Domain 5 Patient Safety April 2013

25. To ensure that anyone accessing NHS-funded services is treated in an environment where their safety is the paramount concern and where the whole system actively seeks to reduce the risks, inherent in health care, to a minimum. Our vision: What we want to achieve over the next decade

26. ““… [we all] need to place the safety of patients at the forefront of the agenda in healthcare. Safety cannot be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.” Sir Ian Kennedy, Chairman Healthcare Commission Patient experience Safety Effectiveness

27. Safety is not a minimum threshold – all services can and should strive to excellence in safety A. Why waste our time on safety? B. We do something when we have an incident C. We have systems in place to manage all identified risks D. We are always on the alert for risks that might emerge E. Risk management is an integral part of everything that we do PATHOLOGICALREACTIVEBUREAUCRATICPROACTIVEGENERATIVE The Manchester Patient Safety Assessment Framework

28. The interplay between patient safety and clinical guidelines It is about the way we safely deliver care once the clinical decision on how to treat has been made – the clinical decision may be the right one but it is not a given that we will deliver it without error.

29. 53,000,000+ people The scale of the challenges 140,000+ different ways the human body can go wrong ICD10 codes 4,300+ ways of treating diseases 6000+ medicines for treating diseases BNF and we wonder why people are harmed….?

30. The scale of the challenges Mid-Staffordshire – and the pockets of it that exist everywhere else 1 in 10 patients admitted experience an adverse event Half of adverse events are judged to be preventable 5% of deaths in English acute hospitals had at least a 50% chance of being preventable Principal problems associated with preventable deaths poor clinical monitoring (31.3%), diagnostic errors (29.7%), and inadequate drug or fluid management (21.1%) Most preventable deaths (60%) occurred in elderly patients with multiple comorbidities and less than 1 year of life left 72% of all patient safety incidents are from the acute sector, 13% from Mental Health, 11% from Community, 2% from Learning Disability, 0.6% from Community Pharmacy and 0.4% from General Practice.

31. National Reporting & Learning System NHS Trusts Practitioners & Staff Patients Carers NRLS CQC MHRA NHS Complaints NHS Litigation Authority International Collaboration Australia USA Europe Standardised reporting Community Pharmacy multiples Commissioners

32. Searching by keywords: example NICE Quality Standard for Bacterial meningitis and meningococcal septicaemia in children Key word search for ‘mening*’ in free text of incident reports identified 182 relevant incidents, all clinically reviewed and themes summarised to inform the development of the Quality Standard

33. We need a trigger

34. Review of Deaths and Severe Harms

35. Local audit data PCT audit of vaccine storage in GP practices shared with NPSA Significant proportion of vaccines stored outside recommended temperature range NRLS Searched National guidance produced NHS | Presentation to [XXXX Company] | [Type Date]34

36. Media Reports, Coroners Courts etc.

37. By 31 March 2012 7,070,261 reports had been reported. Approximately 3,700 incidents are reported to the NRLS per day. Around 94% of incidents cause low or no harm

38. The NHS leads the world in incident reporting, with the National Reporting and Learning System receiving nearly 8 million incident reports since late 2003 to date. Over 100,000 incidents are reported monthly. HES data suggests there are over 100,000 cases of VTE per year NHS Safety Thermometer data suggests 6-7% of patients have a pressure ulcer There were 326 never events reported to SHAs in 2011/2 Levels of Harm

39. Chart 1: Proportion of incidents by care setting for incidents reported to the NRLS 2010/11 NRLS limitations: very little reporting from general practice

40. All care settings: death and severe harm themes 2011/12

41. Fixed priorities Domain 5 of the NHS Outcomes Framework

42. Domain 5: embedded in all domain 1 – 5 work Increase our understanding of the problem Creating the Conditions for Safety Building Capacity for Safety A whole system response to safety Tackling key safety concerns Domains 1 – 4 are expected to build these safety themes into every programme/ project governance arrangement

43. Aim 1 – To increase our understanding of the safety problem Increase our understanding of the problem New methodology for measuring the safety of NHS services (indicator 5c) based on case note review of deaths in hospital Further NHS Safety Thermometers (medicines, mental health, maternity ) Design and deliver the new single incident reporting and management system to replace/upgrade the NRLS and simplify reporting

44. Creating the Conditions for Safety Contract – SIs and HCAI CQUIN and Quality Premium – Pressure ulcer improvement Policy development – Serious incident management, deaths in custody Aim 2: To create the conditions for safer care

45. Safety Expert Groups Patient Safety Skills Strategy Enhanced safety leadership Building Capacity for Safety Aim 3: To build capacity to deliver safer care

46. Patient safety collaboratives Patient safety Improvement Fellows Networks, champions and campaigns A whole system response to safety Aim 4: To create an whole system response to safety

47. Outcomes framework priorities Other key harms Vulnerable groups Tackling key safety concerns Aim 5: To tackle key safety concerns

49. Making the aims a reality Four key delivery streams will be used: 1.Central patient safety development team Development of major initiatives such as reporting systems, safety alerts, commissioning levers, etc 2.Patient Safety Collaboratives Regional effort across boundaries to improve safety concerns 3.National community of interest networks Led by the central patient safety team to link people together working on key safety concerns across the country to accelerate sharing and learning, and support Patient Safety Collaboratives across England 4.Domain 1 – 4 Effectiveness and experience programmes Linking into other developing NHS England programmes of work

50. Berwick Report Implementation Aims for Improvement Building Capacity through training, education, technical capability Structural recommendations; Oversight, accountability and influence Patient and Public Involvement Measurement, transparency, tracking and learning Legal penalties/criminal liability and their impact on safety Implications for leaders at all levels Staff and the work environment

51. Findings Berwick - most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:  Placing the quality of patient care, especially patient safety, above all other aims:  Engaging, empowering, and hearing patients and carers throughout the entire system and at all times:  Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work:  Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

52. Thank you for listening bruce.warner@nhs.net bruce.warner@nhs.net

53. www.sheffieldmca.org.uk